Febrile Seizures in Children: Symptoms, Causes & First Aid

What Are Febrile Seizures?

Febrile seizures are convulsions or fits that occur in children between 6 months and 5 years of age, triggered by a fever, usually above 38.5°C (101.3°F). They affect 2-5% of children and are the most common type of seizure in childhood. Despite appearing alarming, simple febrile seizures are benign and do not cause lasting harm.

Febrile seizures represent the brain's response to a rapid rise in body temperature during childhood. The immature brain of young children is more susceptible to the effects of fever, which can temporarily disrupt normal electrical activity and trigger a seizure. This susceptibility is related to the developmental stage of the brain and typically resolves as the child grows older.

It is important to understand that febrile seizures are distinct from epilepsy. While epilepsy involves recurrent, unprovoked seizures, febrile seizures are provoked by fever and occur only during febrile illnesses. The vast majority of children with febrile seizures do not develop epilepsy later in life.

The medical community classifies febrile seizures into two categories based on their characteristics. Understanding this distinction helps healthcare providers assess the child's risk and determine appropriate follow-up care. Simple febrile seizures are by far the most common type and carry an excellent prognosis.

Simple Febrile Seizures

Simple febrile seizures account for approximately 70-80% of all febrile seizures. These seizures are characterized by generalized tonic-clonic movements affecting the entire body, lasting less than 15 minutes (typically 1-2 minutes), and occurring only once within a 24-hour period. Children with simple febrile seizures have an excellent prognosis with no increased risk of developmental problems or learning difficulties.

During a simple febrile seizure, the child loses consciousness and their body becomes stiff before rhythmic jerking movements begin. The movements affect both sides of the body equally and symmetrically. After the seizure ends, the child may be drowsy and confused for a short period, but this resolves quickly and they return to their normal state.

Complex Febrile Seizures

Complex (or complicated) febrile seizures are less common and have one or more of the following features: duration longer than 15 minutes, focal features (affecting only one part of the body or one side), or occurring more than once within 24 hours. Children with complex febrile seizures may require more thorough evaluation and follow-up, though most still have favorable outcomes.

The distinction between simple and complex febrile seizures is clinically important because complex febrile seizures are associated with a slightly higher risk of recurrence and a marginally increased risk of developing epilepsy later in life. However, it is crucial to emphasize that even with complex febrile seizures, the absolute risk of epilepsy remains relatively low.

Hereditary Component

There is a clear genetic component to febrile seizures. If a parent or sibling has had febrile seizures, the child's risk increases significantly. Studies suggest that children with a first-degree relative who experienced febrile seizures have a 10-20% risk of having one themselves, compared to 2-5% in the general population. This hereditary pattern suggests that genetic factors influence how the developing brain responds to fever.

What Are the Symptoms of Febrile Seizures?

During a febrile seizure, children typically lose consciousness, become stiff, and then experience rhythmic jerking movements of the arms and legs. Their eyes may roll back, skin may appear pale or bluish, and they may be unresponsive. Most seizures last 1-2 minutes and are followed by drowsiness and confusion.

Recognizing the symptoms of a febrile seizure is essential for parents and caregivers. The onset is usually sudden and can occur at the beginning of a febrile illness, sometimes before parents are even aware that the child has a fever. This sudden onset, combined with the dramatic appearance of the seizure, can be extremely frightening for those witnessing it for the first time.

Understanding the typical progression of symptoms can help parents remain calm and respond appropriately. While every seizure may look slightly different, there are common features that characterize most febrile seizures. Being prepared and knowing what to expect can significantly reduce anxiety and enable effective first aid.

During the Seizure

The seizure typically begins with a sudden loss of consciousness. The child becomes unresponsive and will not react to their name being called or to touch. This loss of consciousness occurs because the abnormal electrical activity in the brain temporarily disrupts normal brain function.

Following the loss of consciousness, the body enters the tonic phase. During this phase, the entire body becomes rigid and stiff. The arms may flex at the elbows, and the legs may extend. The child may emit a cry or groan as air is forced out of the lungs through a stiffened diaphragm. This is not a cry of pain or distress - the child is unconscious and unaware.

The tonic phase is followed by the clonic phase, characterized by rhythmic jerking movements of the arms and legs. These movements typically affect both sides of the body equally (bilateral) and are symmetrical. The jerking may be quite vigorous and can be disturbing to witness, but it is important to remember that the child is not experiencing pain during this phase.

• Loss of consciousness: The child becomes completely unresponsive and unaware of surroundings
• Body stiffness: The entire body becomes rigid during the tonic phase
• Head tilting backward: The neck may extend and the head tilt back
• Pale or bluish skin: The skin, especially around the lips, may appear pale or have a bluish tinge due to temporary breathing changes
• Jerking movements: Rhythmic jerking of arms and legs during the clonic phase
• Rolling eyes: The eyes may roll back or deviate to one side
• Drooling or foaming at the mouth: Saliva may accumulate as normal swallowing is temporarily suspended

After the Seizure (Postictal Phase)

When the seizure ends, the child enters what is called the postictal phase. This is a period of recovery during which the brain returns to its normal state. The postictal phase is characterized by drowsiness, confusion, and lethargy. The child may be difficult to wake and may not recognize parents or surroundings immediately.

During the postictal phase, the child's body becomes limp and relaxed. Breathing returns to normal, and color typically improves as oxygen levels normalize. The child may sleep deeply for several minutes to an hour. This sleepiness is normal and should not cause alarm - it is part of the recovery process.

Most children recover completely within 30 minutes to an hour after a simple febrile seizure. They may be somewhat tired or irritable for the rest of the day, but they return to their normal behavior and activity level. There are no lasting effects on brain function, development, or intelligence from simple febrile seizures.

When Should You Seek Medical Care?

Call emergency services immediately if the seizure lasts more than 5 minutes, if your child has difficulty breathing, if they do not regain consciousness within 5 minutes after the seizure ends, or if this is your child's first seizure. For subsequent seizures in a child with known febrile seizures, contact your healthcare provider for guidance.

Understanding when to seek emergency care versus when to contact your regular healthcare provider is crucial for parents of children who have had or are having febrile seizures. While most febrile seizures resolve without medical intervention, certain situations require immediate emergency care.

The decision to seek care depends on several factors, including whether this is the first seizure, the duration of the seizure, and how the child recovers afterward. Parents should not feel embarrassed or worried about seeking care, even if the seizure turns out to be benign. Healthcare providers understand how frightening these episodes can be.

First-Time Seizures

If this is your child's first febrile seizure, it is important to have them evaluated by a healthcare provider, even if the seizure was brief and they seem to have recovered completely. The purpose of this evaluation is to confirm that the seizure was indeed a febrile seizure and not caused by something else, such as an infection of the brain or nervous system.

During the initial evaluation, the healthcare provider will take a detailed history of the seizure, including its duration, appearance, and any associated symptoms. They will perform a physical examination to identify the source of the fever and assess the child's neurological status. In most cases, no additional tests are needed for a simple febrile seizure in a well-appearing child.

Contact Your Healthcare Provider If:

Even after a known febrile seizure, there are situations where you should contact your healthcare provider for guidance:

• Your child has had febrile seizures during multiple separate fever episodes
• The seizure appeared different from previous ones (affecting only one side, longer duration)
• Your child's fever is below 38.5°C (101.3°F) at the time of the seizure
• You have concerns about your child's development or behavior
• Your child is under 6 months or over 5 years of age

When No Immediate Medical Care Is Needed

If your child has previously been diagnosed with febrile seizures and you recognize the seizure as similar to previous episodes, you may not need to seek emergency care if the seizure is brief (less than 5 minutes), your child recovers normally, and you feel confident managing the situation. However, always err on the side of caution if you have any concerns.

How Should You Help a Child During a Febrile Seizure?

Stay calm and protect your child from injury by placing them on a safe surface. Do not restrain them or put anything in their mouth. Time the seizure and place them on their side after it ends. Call emergency services if the seizure lasts more than 5 minutes or if they don't recover normally.

Knowing how to respond during a febrile seizure can help you remain calm and provide appropriate care. The most important things to remember are to keep your child safe, time the seizure, and know when to call for help. With proper first aid, you can help your child through this frightening experience while protecting them from injury.

The key principle of first aid during a seizure is to protect the child while allowing the seizure to run its course. Seizures cannot be stopped by physical intervention, and attempts to do so can result in injury to both the child and the caregiver. Instead, focus on creating a safe environment and gathering information that will be helpful for healthcare providers.

Step-by-Step First Aid

1. Stay calm and note the time. Your composure helps create a calmer environment. Look at a clock or your phone to note when the seizure started. This information is crucial for determining whether emergency services need to be called (seizures lasting more than 5 minutes require immediate medical attention).

2. Ensure safety. Gently guide your child to the floor if they are not already there. Move away furniture, sharp objects, or anything that could cause injury during the seizure. If your child is on a high surface like a bed or changing table, carefully lower them to the floor or stay with them to prevent falling.

3. Position your child on their side. This is called the recovery position and helps keep the airway clear by allowing saliva or vomit to drain from the mouth rather than being aspirated into the lungs. Turn the head slightly to the side if fully rolling them is not possible.

4. Loosen tight clothing. Remove or loosen any clothing around the neck, such as collars or ties, to make breathing easier. Do not attempt to remove all clothing - focus only on items that may restrict breathing.

5. Do NOT restrain your child. Do not hold your child down or try to stop the jerking movements. This can cause injury to both of you and does not help stop the seizure. Allow the movements to occur naturally while ensuring the child is in a safe position.

6. Do NOT put anything in their mouth. There is a common misconception that people can swallow their tongue during a seizure. This is not true. Putting objects in the mouth can cause broken teeth, jaw injury, or aspiration of foreign material. Keep your fingers away from your child's mouth as well.

7. Do NOT give food, water, or medication by mouth. During and immediately after a seizure, the swallowing reflex is impaired. Giving anything by mouth can lead to choking or aspiration.

When to Use Rescue Medication

Some children who have had prolonged febrile seizures or are at high risk of long seizures may be prescribed rescue medication (such as rectal diazepam or buccal midazolam) to stop seizures that last more than 5 minutes. If your child has been prescribed rescue medication, your healthcare provider will provide specific instructions on when and how to use it.

It is important to practice using rescue medication before you need it. Many parents feel anxious about administering medication during a seizure, and practicing helps build confidence. Your healthcare provider or pharmacist can demonstrate the proper technique.

What Causes Febrile Seizures?

Febrile seizures are caused by fever, typically when body temperature rises rapidly above 38.5°C (101.3°F). They occur because the immature brain of young children is more susceptible to the effects of fever. Common triggers include viral infections (colds, flu, roseola), ear infections, and other childhood illnesses. There is also a strong genetic component.

The exact mechanism by which fever triggers seizures in susceptible children is not completely understood, but research has provided significant insights into the underlying processes. The immature brain of young children responds differently to fever than the adult brain, and this difference is thought to be central to the development of febrile seizures.

During fever, the body's temperature regulation system raises the set point for body temperature as part of the immune response to infection. This elevated temperature affects the electrical activity in the brain. In children with a susceptibility to febrile seizures, this alteration in brain activity can reach a threshold that triggers a seizure.

The Role of Fever

Fever itself, rather than the underlying illness, is the trigger for febrile seizures. Seizures typically occur early in the course of a febrile illness, often when the fever is rising rapidly. In fact, a febrile seizure may be the first sign that a child has a fever - many parents report that they were unaware their child was ill until the seizure occurred.

The height of the fever matters less than the rate of temperature rise. Seizures can occur with relatively low fevers (just above 38°C/100.4°F) if the temperature rises quickly, while higher fevers may not cause seizures if the temperature rises gradually. This is why fever-reducing medications, which lower the temperature but don't affect how quickly it rises, are not effective at preventing febrile seizures.

Common Infections That Trigger Febrile Seizures

Any infection that causes fever can potentially trigger a febrile seizure. However, some infections are more commonly associated with febrile seizures than others:

• Viral upper respiratory infections: Common colds and flu are the most frequent triggers
• Roseola (human herpesvirus 6): This common childhood viral illness causes high fevers and is strongly associated with febrile seizures
• Ear infections (otitis media): Middle ear infections are common in young children and often cause fever
• Gastroenteritis: Stomach viruses can cause fever along with vomiting and diarrhea
• Urinary tract infections: May cause fever, especially in young children

Post-Vaccination Febrile Seizures

Some vaccines, particularly the measles-mumps-rubella (MMR) vaccine and the diphtheria-tetanus-pertussis (DTaP) vaccine, can occasionally cause fever that triggers febrile seizures. These seizures typically occur 8-14 days after MMR vaccination (when the live attenuated virus replicates and may cause mild fever) and within 1-3 days after DTaP vaccination.

It is important to emphasize that the risk of febrile seizures from vaccines is very small, and the benefits of vaccination far outweigh this risk. The American Academy of Pediatrics, the World Health Organization, and other medical organizations strongly recommend that children receive all scheduled vaccinations, including those that may rarely cause fever. Febrile seizures from vaccines, like other febrile seizures, are generally benign.

Why Only Some Children Get Febrile Seizures

The reason febrile seizures occur in some children but not others relates to individual differences in brain development and genetic factors. Research has identified several genes that influence susceptibility to febrile seizures, and the condition tends to run in families. If a parent or sibling has had febrile seizures, the risk for other children in the family is significantly higher.

The brain's susceptibility to febrile seizures appears to be age-dependent. Children under 6 months rarely have febrile seizures because maternal antibodies may provide some protection against the infections that cause fever. After age 5-6, the brain has matured sufficiently that it is no longer susceptible to fever-induced seizures in most children.

How Are Febrile Seizures Diagnosed?

Febrile seizures are diagnosed based on the clinical history - the child's age (6 months to 5 years), presence of fever, and characteristic seizure description. Most children with simple febrile seizures do not need any tests. Additional evaluation may be considered for complex febrile seizures or if there are concerns about underlying causes.

The diagnosis of febrile seizures is primarily clinical, meaning it is based on the history provided by parents or caregivers and the physical examination, rather than on specific tests. When a child presents after a seizure with fever, the healthcare provider's main goals are to confirm that the event was a febrile seizure, identify the source of the fever, and ensure there is no serious underlying cause such as meningitis.

The healthcare provider will ask detailed questions about the seizure, including what the child looked like, how the seizure progressed, how long it lasted, and what happened afterward. They will also ask about the child's medical history, developmental milestones, and family history of febrile seizures or epilepsy. This information helps determine whether the seizure fits the pattern of a typical febrile seizure.

Physical Examination

The physical examination focuses on identifying the source of the fever and assessing the child's neurological status. The provider will look for signs of infection such as ear infection, throat infection, or respiratory illness. They will also perform a neurological examination to ensure the child has returned to their normal baseline.

Most children with simple febrile seizures will have a normal physical examination once they have recovered from the postictal phase. The examination helps reassure both the healthcare provider and the parents that there is no underlying serious condition.

When Are Tests Needed?

For most children with simple febrile seizures, no laboratory tests, imaging studies, or electroencephalograms (EEGs) are needed. The American Academy of Pediatrics and other medical organizations have published guidelines that emphasize avoiding unnecessary testing in well-appearing children with simple febrile seizures.

Additional evaluation may be considered in certain situations:

Electroencephalogram (EEG)

An EEG is a test that records the electrical activity of the brain. For simple febrile seizures, an EEG is not routinely recommended because it does not predict which children will have future febrile seizures or develop epilepsy. The EEG may show minor abnormalities in children with febrile seizures, but these findings do not change management.

An EEG may be considered for children with complex febrile seizures, particularly those with focal features or prolonged duration, or for children with developmental delays or neurological abnormalities. In these cases, the EEG may provide additional information about the risk of epilepsy.

How Are Febrile Seizures Treated?

Most febrile seizures stop on their own within 1-2 minutes and do not require specific treatment. Management focuses on keeping the child comfortable during the underlying illness and knowing how to respond if another seizure occurs. Daily preventive medication is not recommended for most children with febrile seizures.

The approach to febrile seizures has evolved significantly over the years. Medical evidence has consistently shown that simple febrile seizures are benign and do not require aggressive treatment. The focus of management has shifted from trying to prevent seizures to ensuring parents are educated about how to respond and when to seek care.

Understanding that febrile seizures are a self-limited condition that children outgrow is an important part of treatment. While witnessing a seizure can be traumatic for parents, knowing that these events do not cause harm to the child can provide significant reassurance.

During the Seizure

The primary intervention during a febrile seizure is supportive care - keeping the child safe and positioned on their side. Most seizures resolve spontaneously within 1-2 minutes. If the seizure continues for more than 5 minutes, emergency services should be called and rescue medication (if prescribed) should be administered.

In the emergency department or hospital setting, prolonged seizures may be treated with benzodiazepine medications (such as diazepam or lorazepam) given intravenously or rectally. These medications are effective at stopping seizures but are not needed for the vast majority of febrile seizures, which stop on their own.

Fever Management

It is natural for parents to want to prevent future seizures by aggressively controlling fever. However, research has consistently shown that antipyretic medications (fever reducers like acetaminophen/paracetamol or ibuprofen) do not prevent febrile seizures. This is because seizures typically occur when the fever is rising rapidly, often before parents are even aware the child is ill.

Nevertheless, fever-reducing medications can make a sick child more comfortable and are appropriate to use during febrile illnesses. They should be given according to package directions and the child's weight. Other comfort measures include light clothing, adequate fluids, and rest.

Preventive Treatment

Daily preventive medication (such as anti-seizure drugs) is generally not recommended for children with simple febrile seizures. The risks and side effects of long-term medication outweigh the benefits, especially given the benign nature of simple febrile seizures. Studies have shown that while daily anti-seizure medications can reduce the frequency of febrile seizures, they do not reduce the risk of later epilepsy and carry significant side effects.

In rare cases, intermittent prophylaxis with diazepam during febrile illnesses may be considered for children with very frequent febrile seizures or those who are very anxious about recurrence. However, this approach has drawbacks including sedation during illness and the practical difficulty of predicting when fever will occur.

Rescue Medication

Some children, particularly those who have had prolonged febrile seizures (lasting more than 5 minutes), may be prescribed rescue medication to have at home. This medication (typically rectal diazepam or buccal midazolam) can be given by parents if a seizure lasts longer than 5 minutes, with the goal of stopping the seizure before it becomes very prolonged.

If your child is prescribed rescue medication, make sure you understand when and how to use it. Practice the administration technique so you feel confident if you need to use it. Keep the medication accessible but out of reach of children, and check expiration dates regularly.

What Is the Long-Term Outlook for Children with Febrile Seizures?

The prognosis for children with febrile seizures is excellent. Simple febrile seizures do not cause brain damage, developmental delays, or learning problems. Most children outgrow febrile seizures by age 6. The risk of developing epilepsy is only slightly higher than the general population (2-4% vs 1-2%).

One of the most important messages for parents of children with febrile seizures is that the long-term outlook is overwhelmingly positive. Decades of research have consistently shown that simple febrile seizures do not cause lasting harm to the brain or affect cognitive development. Children who have had febrile seizures perform normally on intelligence tests and academic assessments.

The natural history of febrile seizures is that children outgrow them as the brain matures. By age 6, the brain has developed past the stage where it is susceptible to fever-induced seizures, and most children will not have febrile seizures after this age. For the rare child who continues to have seizures after age 6, evaluation for other causes may be appropriate.

Risk of Recurrence

Approximately one-third of children who have one febrile seizure will have another one during a subsequent febrile illness. The risk of recurrence is higher in children who had their first febrile seizure before age 18 months, those with a family history of febrile seizures, those whose first seizure occurred with a relatively low fever, and those who had their seizure early in the course of the illness.

Having a recurrent febrile seizure does not change the excellent prognosis. Multiple febrile seizures, as long as they remain simple in type, still do not cause brain damage or developmental problems. However, each subsequent seizure can be emotionally difficult for families, which is why education and preparation are so important.

Risk of Developing Epilepsy

The risk of developing epilepsy after simple febrile seizures is only slightly higher than the general population - approximately 2-4% compared to 1-2% in children who never had febrile seizures. This means that 96-98% of children with simple febrile seizures will NOT develop epilepsy.

The risk of epilepsy is somewhat higher in children with complex febrile seizures, those with a family history of epilepsy, and those with pre-existing neurodevelopmental abnormalities. However, even in these groups, the majority of children do not develop epilepsy.

Can Febrile Seizures Be Prevented?

Research shows that fever-reducing medications (antipyretics) do not prevent febrile seizures, as seizures often occur before parents notice the fever or when the fever is rapidly rising. There is no proven way to prevent febrile seizures. The focus should be on knowing how to respond if a seizure occurs rather than trying to prevent it.

The desire to prevent febrile seizures is completely understandable. Having witnessed their child have a seizure, most parents want to do everything possible to prevent another one. Unfortunately, despite years of research, no method has been proven effective at preventing febrile seizures.

The reason fever-reducing medications don't prevent febrile seizures relates to the nature of how these seizures occur. Febrile seizures typically happen when the temperature is rising rapidly, often as the first sign of illness before parents are aware the child has a fever. By the time the fever is detected and medication is given, the critical period has already passed.

What Doesn't Work

Multiple high-quality studies have shown that giving acetaminophen (paracetamol) or ibuprofen at the first sign of fever does not reduce the risk of febrile seizures. Similarly, alternating between these medications, giving them around the clock, or using them prophylactically during illness has not been shown to be effective.

Tepid sponge baths, which were once recommended to reduce fever, are no longer advised. They can cause discomfort and shivering, which may actually raise body temperature. More importantly, like fever-reducing medications, they do not prevent febrile seizures.

Focus on Preparedness

Rather than focusing on prevention, parents should focus on being prepared to respond appropriately if a seizure occurs. This means knowing the first aid steps, understanding when to call emergency services, and having a plan in place. Many parents find it helpful to inform other caregivers (such as grandparents, daycare providers, and babysitters) about their child's febrile seizures and what to do if one occurs.

Being prepared also means having rescue medication readily available if it has been prescribed, knowing where the nearest emergency department is located, and having emergency contact numbers easily accessible. This preparation can significantly reduce anxiety and ensure a faster response if a seizure occurs.